Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0630

2. Registrant Information.

Registrant Reference Number: PROSAR case#:1-35717677

Registrant Name (Full Legal Name no abbreviations): HACCO, Inc.

Address: 110 Hopkins Drive

City: Randolph

Prov / State: Wisconsin

Country: USA

Postal Code: 53956

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

10-DEC-13

5. Location of incident.

Country: UNITED STATES

Prov / State: WEST VIRGINIA

6. Date incident was first observed.

Unknown

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 61282-46

Product Name: Ramik Green

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Guarantee/concentration .005 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Blood
  • Symptom - Bleeding

• Eye
  • Symptom - Swollen eye

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-35717677 - The reporter, a pet owner, indicated that his dog may have been exposed to a rodenticide containing the active ingredient diphacinone. The reporter stated that he came home and found that one of his dogs had gotten into the product sometime during the day. Veterinary care was recommended, where the antidote, vitamin K1 could be prescribed. On follow-up call, six days later, the reporter indicated that one of his dogs was bleeding out of his eye and the eye was swollen. The reporter had not sought veterinary care for any of his dogs and indicated that he was treating his sick dog at home with mineral oil and a human dose of vitamin K1. Immediate veterinary care was recommended where the appropriate does of vitamin K1 could be provided. On a second follow-up call, eight days after the initial call, the reporter indicated that the sick dog died last night. The reporter did not seek veterinary care. All other dogs remained asymptomatic. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here